Approved DME Medicaid Provider

Transcription

1 2018 Product Catalog 900 Commonwealth Pl Suite 200 Virginia Beach, VA Orders: Office: Page 3 Page 4 Page 5 Approved DME Medicaid Provider

2 A4216 A4217 A4244 A4246 A4247 A4450 A4452 A4461 A4463 A6010 A6011 A6021 A6022 A6023 A6024 A6025 A6154 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 DESCRIPTION (Bandages, Dressings, Gauze and Tape) Sterile water, saline and/or dextrose, diluent/flush, 10 ml Sterile water/saline 500 ml Alcohol or peroxide, per pint Betadine or phisohex solution, per pint Betadine or iodine swabs/wipes, per box Tape, non-waterproof, per 18 square inches Tape, waterproof, per 18 square inches Surgical dressing holder, non-reusable, each Surgical dressing holder, reusable, each Collagen based wound filler, dry form, per gram of collagen Collagen based wound filler, gel/paste, per gram of collagen Collagen dressing, sterile, pad size 16 sq. in. or less, each Collagen dressing, sterile, pad size more than 16 sq. in but less than or equal to 48 sq. in., each Collagen dressing, sterile, pad size more than 48 sq. in., each Collagen dressing wound filler, per 6 in Gel sheet, for dermal or epidermal applications, (e.g. silicone, hydrogel, other), each Wound pouch, each Alginate or other fiber gelling dressing, wound cover, pad size 16 sq. in. or less, each dressing Alginate or other fiber gelling dressing, wound cover, pad size more than 16 sq. in. but less than 48 sq. in., each dressing Alginate or other fiber gelling dressing, wound cover, pad size more than 48 sq. in. each dressing Alginate or other fiber gelling dressing, wound filler, per 6 inches Composite dressing, pad size 16 sq. in. or less, with any size adhesive border, each dressing Composite dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., any size with adhesive border, each dressing Composite dressing, pad size more than 48 sq. in., with any size adhesive border, each dressing Contact layer, 16 sq. in. or less, each dressing Contact layer, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing Contact layer, more than 48 sq. in., each dressing Foam dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing Foam dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Foam dressing, wound cover pad size more than 48 sq. in., without adhesive border, each dressing

3 A6212 A6213 A6214 A6215 A6216 A6217 A6218 A6219 A6220 A6221 A6222 A6223 A6224 A6228 A6229 A6230 A6231 A6232 A6233 A6234 A6235 DESCRIPTION (Bandages, Dressings, Gauze and Tape) Foam dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Foam dressing, wound cover, pad size more than 16 sq. In. but less than 48 sq. in, with any size adhesive border, each dressing Foam dressing, wound cover pad size more than 48 sq. in., with any size adhesive border, each dressing Foam dressing, wound filler, per gram Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing Gauze, non-impregnated, pad size 16 sq. in. or less, with any size adhesive border, each dressing Gauze, non-impregnated, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Gauze, non-impregnated, pad size more than 48 sq. in., with any size adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, impregnated with other than water, normal saline, or hydrogel, pad size more than 48 sq. in., without adhesive border, each dressing Gauze, impregnated, water or normal saline, pad size 16 sq. in. or less, without adhesive border, each dressing Gauze, impregnated, water or normal saline, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing Gauze, impregnated, water or normal saline, pad size more than 48 sq. in., without adhesive border, each dressing Gauze, impregnated, hydrogel, for direct wound contact, pad size 16 sq. in. or less, each dressing Gauze, impregnated, hydrogel, for direct wound contact, pad size greater than 16 sq. in. but less than or equal to 48 sq.in., each dressing Gauze, impregnated, hydrogel, for direct wound contact, pad size more than 48 sq. in., each dressing Hydrocolloid dressing, wound cover, pad size 16 sq. in. or less without adhesive border, each dressing. Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing

4 A6236 A6237 A6238 A6239 A6240 A6241 A6242 DESCRIPTION (Bandages, Dressings, Gauze and Tape) Hydrocolloid dressing, wound cover, pad size more than 48 sq. in., without adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size 16 sq. in., or less, with any size adhesive border, each dressing Hydrocolloid dressing, wound cover, pad size more than 16 sq. in., but less than or equal to 48 sq. in., with any size adhesive border, each dressing Hydrocolloid, dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Hydrocolloid dressing, wound filler, paste, per fluid ounce Hydrocolloid dressing, wound filler, dry form, per gram Hydrogel dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing A6243 Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in. without adhesive border, each dressing A6244 A6245 A6246 A6247 A6248 A6250 A6251 Hydrogel dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing Hydrogel dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 16 sq. in. but less than 48 sq. in. with any size adhesive border, each dressing Hydrogel dressing, wound cover, pad size more than 48 sq. in. with any size adhesive border, each dressing Hydrogel dressing, wound filler, gel, per fluid ounce Skin sealants, protectants, moisterizers, ointments, any type, any size Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, without adhesive border, each dressing A6252 Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than 48 sq. in. without adhesive border, each dressing A6253 A6254 A6255 A6256 A6257 A6258 A6259 Specialty absorptive dressing, wound cover, pad size more than 48 sq. in. without adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size 16 sq. in. or less, with any size adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing Specialty absorptive dressing, wound cover, pad size more than 48 sq. in., with any size adhesive border, each dressing Transparent film, 16 sq. in. or less, each dressing Transparent film, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing Transparent film more than 48 sq. in., each dressing

5 A6260 A6261 A6262 A6266 A6402 DESCRIPTION (Bandages, Dressings, Gauze and Tape) Wound cleansers, any type, any size Wound filler, gel/paste, per fluid ounce, not elsewhere classified Wound filler, dry form, per gram, not elsewhere classified Gauze, impregnated, other than water, normal saline, or zinc paste, any width, per linear yard Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing A6403 Gauze, non-impregnated, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing A6404 A6407 A6410 A6411 A6412 A6413 A6441 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451 Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing Packing strips, non-impregnated, up to two inches in width, per linear yard Eye Pad, sterile, each Eye Pad, non-sterile, each Eye Patch, occlusive, each Adhesive bandage, first-aid type, any size, each Padding, bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to five inches, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard Light compression bandage, elastic, knitted/woven, width less than three inches Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50 percent maximum stretch, width greater than or equal to 3 in. and less than 5 in.

6 A6452 A6453 A6454 A6455 A6456 A6457 DESCRIPTION (Bandages, Dressings, Gauze and Tape) High compression bandage, elastic, kitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50 percent maximum stretch, width greater than or equal to 3 in. and less than 5 in. Self-adherent bandage, elastic, non-knitted/non-woven, width less than 3 in. Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to 3 in. and less than 5 in. Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to 5 in. Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to 3 in. and less than 5 in. Tubular dressing with or without elastic, any width Clamp, Cannula Sterile Barrier Fields, Any Size Sterile Q-Tips Sterile Specimen Cups Steri-Strip Skin Closures Suture Removal Tray Twill Tape

7 A4206 A4250 A4253 A4256 A4258 A4259 A4245 S8490 S5560 S5561 ITEM # E0607 E2100 E2101 E0607 RR E2100 RR E2101 RR ITEM # A4230 A4231 A4232 A4225 E0784 E0784 RR ITEM # A9276 A9277 A9277 RR A9278 A9278 RR Syringe with needle, sterile, 1cc or less, each Urine test or reagent strips or tablet DESCRIPTION (Supplies) Blood glucose test or reagent strips for home blood glucose monitor, Normal, low, and high calibrator solution/chips Spring-powered device for lancet Lancets Alcohol wipes Single use, Safety lancets Medicine Dropper Insulin Syringes Insulin delivery device, reusable pen, 1.5 ml size Insulin delivery device, reusable pen, 3 ml size Home blood glucose monitor DESCRIPTION (Glucose Monitors) Blood glucose monitor with integrated voice synthesizer Blood glucose monitor with integrated lancing/blood sample Home blood glucose monitor Blood glucose monitor with integrated voice synthesizer Blood glucose monitor with integrated lancing/blood sample DESCRIPTION (Insulin Pumps and Supplies) Infusion set for external insulin pump, non-needle cannula type Infusion set for external insulin pump, needle type Syringe with needle for external insulin pump, sterile 3cc Supplies for external insulin infusion pump, syringe type cartridge, sterile, each External ambulatory infusion pump, insulin External ambulatory infusion pump, insulin DESCRIPTION (Continuous Glucose Monitor (CGM)) Sensor; invasive (e.g. Subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit Transmitter; external, for use with interstitial continuous glucose monitoring system Transmitter; external, for use with interstitial continuous glucose monitoring system (Pregnant individuals with Type 1 or Type 2 diabetes) Receiver (monitor); external, for use with interstitial continuous glucose monitoring system Receiver (monitor); external, for use with interstitial continuous glucose monitoring system (Pregnant individuals with Type 1 or Type 2)

8 A4233 A4234 A4235 A4236 DESCRIPTION (Replacement Batteries) Replacement battery, alkaline (other than J cell), for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, alkaline, J cell, for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each

9 A4216 A4217 A4361 A4363 A4366 A4367 A4368 A4394 A4395 A4396 A4397 A4398 A4399 A4400 A4404 A4421 A4421 A4422 A4456 A4455 A5055 A5056 A5057 A5081 A5082 A5083 A5093 A5102 A5105 A5126 A5131 A5200 DESCRIPTION (Ostomy/Colostomy Products / Ostomy Accessories) Sterile water, saline and /or dextrose, diluent/flush, 10 ml Sterile water/saline 500 ml Ostomy Face Plate Ostomy clamp, any type, replacement only, each Ostomy vent, any type, each Ostomy Belt Ostomy filter, any type, each Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce Ostomy deodorant for use in Ostomy pouch, solid. Per tablet Ostomy belt with peristomal hernia support Irrigation Supply; Sleeve Ostomy irrigation supply; bag; each Ostomy Irrigation Bag, cone/catheter, including brush Ostomy Irrigation Set Ostomy Rings All Sizes Ostomy supply miscellaneous (Any Misc Ostomy/Colostomy supplies without a HCPCS code should use A4421 instead of ) Stoma Cone Replacement Unit (Using ostomy supply misc.) Ostomy absorbent material (sheet/pad/crystal packet), for use on Ostomy pouch to thicken liquid stoma output, each Adhesive Remover, Wipes, any type, each Adhesive Remover Or Solvent (for tape, cement or other adhesive), Stoma Caps Ostomy Pouch, Drainable, with extended wear barrier attached, with filter (1 piece) each Ostomy Pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece) each Continent device; plug for continent stoma Continent device; catheter for continent stoma Continent device, stoma absortive cover for continent stoma Ostomy Accessory, Convex Insert Bedside drainage bottle, with or without tubing, rigid or expandable, each Urinary suspensory with leg bag, with or without tube, each Adhesive or non-adhesive; Disc Or Foam Pad Appliance cleaner, incontinence and Ostomy appliances, per 16 oz Percutaneous catheter/tube anchoring device, adhesive skin attachment ITEM # DESCRIPTION (Ostomy Pouches)

10 A4375 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4387 A4388 A4389 DESCRIPTION (Ostomy Pouches) Ostomy pouch, drainable, with faceplate attached, plastic, each Ostomy pouch, drainable, with faceplate attached, rubber, each Ostomy pouch, drainable, for use on faceplate, plastic, each Ostomy pouch, drainable, for use on faceplate rubber, each Ostomy pouch urinary, with faceplate attached, plastic, each Ostomy pouch urinary, with faceplate attached, rubber, each Ostomy pouch urinary, for use on faceplate, plastic, each Ostomy pouch urinary, for use on faceplate, heavy plastic, each Ostomy pouch urinary, for use on faceplate, rubber, each Ostomy pouch, closed, with barrier attached, with built in convexity (one piece), each Ostomy pouch, drainable, with extended wear barrier attached, (one piece), each Ostomy pouch drainable, with barrier attached, with built in convexity (one piece), each A4390 Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity (1 piece), each A4391 A4392 A4393 A4411 A4412 A4413 A4416 A4417 A4418 A4419 A4420 A4423 A4424 A4425 A4426 Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each Ostomy pouch, urinary, with standard wear barrier attached, with built in convexity (1 piece), each Ostomy pouch, urinary, with extended wear barrier attached, with built in convexity, (1 piece), each Ostomy skin barrier, solid 4x4 or equivalent, extended wear, with built-in convexity, each Ostomy pouch, drainable, high output, for use on a barrier with flange, (2 piece system), without filter, each Ostomy pouch, drainable, high output, for use on a barrier with flange, (2 piece system), with filter, each Ostomy pouch, closed, with barrier attached, with filter (one piece), each Ostomy pouch, closed, with barrier attached, with built in convexity, with filter (one piece), each Ostomy pouch, closed; with out barrier attached, with filter (one piece), each Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (two piece), each Ostomy pouch, closed; for use on barrier with locking flange, (two piece), each Ostomy pouch, closed; for use on barrier with locking flange, with filter (two piece), each Ostomy pouch, drainable, with barrier attached, with filter (one piece), each Ostomy pouch, drainable, for use on barrier with non-locking flange, with filter (two piece system), each Ostomy pouch drainable, for use on barrier with locking flange, (two piece system), each

11 A4427 A4428 A4429 A4430 A4431 A4432 A4433 A4434 A4435 A5051 A5052 A5053 A5054 A5061 A5062 A5063 A5071 A5072 ITEM A5073# A4362 A4364 A4369 A4371 A4372 A4373 A4384 A4385 DESCRIPTION (Ostomy Pouches) Ostomy pouch drainable, for use on barrier with locking flange, with filter (two piece system), each Ostomy pouch, urinary, with extended wear barrier attached, with faucet type tap with valve (one piece), each Ostomy pouch, urinary, with barrier attached with built in convexity, with faucet type tap with valve (one piece), each Ostomy pouch, urinary, with extended wear barrier attached with built in convexity, with faucet type tap with valve (one piece), each Ostomy pouch, urinary, with barrier attached with faucet type tap with valve (one piece), each Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet type tap with valve (two piece), each Ostomy pouch, urinary; for use on barrier with locking flange, (two piece), each Ostomy pouch, urinary; for use on barrier with locking flange, with faucet type tap with valve (two piece), each Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filer, each Ostomy Pouch, Closed W/Barriers Attached, 1 Piece Ostomy Pouch Closed Without Barrier Attached, 1 Piece Ostomy Pouch, Closed For Use On Face Plate Ostomy Pouch Closed For Use On A Barrier With Flange, 2 Pieces, does not say closed or mini pouch Ostomy Pouch, Drainable, W/Barrier Attached; 1 piece Ostomy Pouch, Drainable Without Barrier Attached, 1 Piece Ostomy Pouch, Drainable, For Use On Barrier W/Flange, 2 Piece System Ostomy Pouch Urinary W/Barrier Attached 1 Piece Ostomy Pouch Urinary Without Barrier Attached, 1 Piece Ostomy Pouch DESCRIPTION Urinary For (Ostomy Use On Skin Barrier Barrier With Liquids, Flange, Pastes, 2 Pieces Powder And Rings) Ostomy Skin Barrier; Solid, 4x4 Or Equivalent Adhesive liquid or equal, any type Ostomy skin barrier, liquid (spray, brush, etc.), per oz. Ostomy skin barrier powder, per oz. Ostomy skin barrier, solid 4x4 or equivalent, with built-in convexity, each Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each Ostomy faceplate equivalent, silicone ring, each Ostomy skin barrier, solid 4X4 or equivalent, extended wear, without built-in convexity, each

12 A4405 A4406 A4407 A4408 A4409 A4410 A4414 A4415 A5120 A5121 A5122 DESCRIPTION (Ostomy Skin Barrier Liquids, Pastes, Powder And Rings) Ostomy skin barrier, non-pectin based, paste, per ounce Ostomy skin barrier, pectin-based, paste, per ounce Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built in convexity, 4x4 inches or smaller, each Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built in convexity, larger than, 4x4 inches, each Ostomy skin barrier, with flange, (solid, flexible, or accordion), extended wear, without built-in convexity, 4X4 inches or smaller, each Ostomy skin barrier, with flange, (solid, flexible, or accordion), extended wear, without built-in convexity, larger than 4X4 inches, each Ostomy skin barrier, with flange (solid, flexible, or accordion), with out built in convexity 4x4 inches or smaller, each Ostomy skin barrier, with flange (solid, flexible, or accordion), with out built in convexity, larger than 4x4 inches, each Skin Barrier Wipes or swabs, each Skin Barrier, Solid 6x6 Or Equiv. Skin Barrier, solid, 8x8 Or Equivalent

13 PRICE (DME and Supplies Listing) ITEM # A4265 A4402 A4456 A4458 A4459 A4561 A4562 A4565 A4566 A4467 A4600 A4601 A4602 A4611 A4611 RR A4612 A4612 RR A4613 A4613 RR A4638 A4660 A4670 A4927 A4930 A9901 E0160 E0160 RR E0161 E0161 RR DESCRIPTION (Miscellaneous Durabable and Expendable Supplies) Paraffin Lubricant - All Brands Adhesive remover, wipes, any type, each Enema bag w/tubing, reusable Manual pump-operated enema system, includes ballon, catheter and all accessories, resuable any type Pessary; rubber, any type Pessary, non rubber, any type Sling-Any Type Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustment. Belt, strap, sleeve, garment, or covering any type Sleeve for intermittent limb compression device, replacement only, each Lithuim ion battery for non-prosthetic use, replacement Replacement battery for external infusion pump owned by patient, lithium,1.5 volt, each Battery, heavy duty; replacement for patient-owner ventilator Battery, heavy duty; replacement for patient-owner ventilator Battery, cables; replacement for patient-owner ventilator Battery, cables; replacement for patient-owner ventilator Battery, charger; replacement for patient-owner ventilator Battery, charger; replacement for patient-owner ventilator Replacement battery, for patient owned ear pulse generator, each Sphygmomanometer/Bp Apparatus W/Cuff And Stethoscope Automatic Blood Pressure Monitor Gloves, Non-Sterile, Sm., Med., Lrg. Gloves, Sterile, Sm., Med., Lrg. DME Delivery, set up, and/or dispensing service component of another HCPCS code Sitz bath or equipment, portable, used with or without commode Sitz bath or equipment, portable, used with or without commode Sitz type bath or equipment, portable, used with or without commode, with faucet attachment's) Sitz type bath or equipment, portable, used with or without commode, with faucet attachment's)

14 E0162 E0162 RR E0163 E0163 RR E0165 E0165 RR E0167 E0167 RR E0168 E0168 RR E0170RR E0175 E0175 RR E0202 RR E0235 E0235 RR E0236 E0236 RR E0239 E0239 RR E0240 E0244 E0245 E0246 E0247 E0248 E0249 E0249 RR E0602 E0603 E0604 DESCRIPTION (Miscellaneous Durabable and Expendable Supplies) Sitz bath chair Sitz bath chair Commode chair, mobile or stationary, with fixed arms Commode chair, mobile or stationary, with fixed arms Commode chair, mobile or stationary, with detachable arms Commode chair, mobile or stationary, with detachable arms Pail or pan for use with commode chair, replacement only Pail or pan for use with commode chair, replacement only Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each Commode chair, stationary with pail Foot rest, for use with commode chair, each Foot rest, for use with commode chair, each Phototherapy (bilirubin) light with photometer Paraffin bath unit, portable Paraffin bath unit, portable Pump for water circulating pad Pump for water circulating pad Hydrocollator unit, portable Hydrocollator unit, portable Bath/Shower chair, with or without wheels, any size Raised Toilet Seat Tub stool or bench Transfer tub rail attachment Transfer bench for tub or toilet with or without commode opening Transfer bench, heavy duty, for tub or toilet with or without commode opening Pad for water circulating heat unit Pad for water circulating heat unit Breast pump, manual, any type Breast pump, electric (AC and/or DC), any type Breast pump, hospital grade, electric (AC and/or DC), any type

15 E0610 E0610 RR E0621 E0621 RR E0630 E0630 RR E0638 E0638 RR E0641 E0641 RR E0642 E0642 RR E0650 E0650 RR E0651 E0651 RR E0652 E0652 RR E0655 E0655 RR E0656 E0656 RR E0657 E0657 RR E0660 E0660 RR E0665 E0665 RR E0666 DESCRIPTION (Miscellaneous Durabable and Expendable Supplies) Pacemaker monitor, self contained, checks battery depletion, includes audible and visible check systems Pacemaker monitor, self contained, checks battery depletion, includes audible and visible check systems Sling or seat, patient lift, canvas or nylon Sling or seat, patient lift, canvas or nylon Patient lift, hydraulic or mechanical, includes any seat, sling, strap (s) or pad(s) Patient lift, hydraulic or mechanical, includes any seat, sling, strap (s) or pad(s) Standing frame /Table system, One Position (E.G. Upright, Supine or Prone Stander), any Size Including Pediatric, With or Without Wheels Standing frame /Table system, One Position (E.G. Upright, Supine or Prone Stander), any Size Including Pediatric, With or Without Wheels Standing Frame/Table System, Multi-Postion (E.G. Three-Way Stander), Any Size Including Pediatric, With or Without Wheels Standing Frame/Table System, Multi-Postion (E.G. Three-Way Stander), Any Size Including Pediatric, With or Without Wheels Standing Frame/Table System, Mobile (Dynamic Stander), Any Size Including Pediatric Standing Frame/Table System, Mobile (Dynamic Stander), Any Size Including Pediatric Pneumatic compressor, nonsegmental home model Pneumatic compressor, nonsegmental home model Pneumatic compressor, segmental home model without calibrated gradient pressure Pneumatic compressor, segmental home model without calibrated gradient pressure Pneumatic compressor, segmental home model with calibrated gradient pressure Pneumatic compressor, segmental home model with calibrated gradient pressure Nonsegmetal Pneumatic appliance for use with pneumatic compressor, half arm Nonsegmetal Pneumatic appliance for use with pneumatic compressor, half arm Segmnetal pneumatic appliance for use with pneumatic compressor, trunk Segmnetal pneumatic appliance for use with pneumatic compressor, trunk Segmental pneumatic appliance for use with pneumatic compressor, chest Segmental pneumatic appliance for use with pneumatic compressor, chest Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm Nonsegmetal Pneumatic appliance for use with pneumatic compressor, half leg

16 E0666 RR E0667 E0667 RR E0668 E0668 RR E0669 E0669 RR E0670 E0670 RR E0671 E0671 RR E0672 E0672 RR E0673 E0673 RR E0675RR E0676 E0676 RR E0705 E0705 RR E0935 RR E0936 RR E0968 E0968 RR E1800 RR E1801 RR E1802 RR E1805 RR E1806 RR E1810 RR DESCRIPTION (Miscellaneous Durabable and Expendable Supplies) Nonsegmetal Pneumatic appliance for use with pneumatic compressor, half leg Segmental pneumatic appliance for use with pneumatic compressor, full leg Segmental pneumatic appliance for use with pneumatic compressor, full leg Segmental pneumatic appliance for use with pneumatic compressor, full arm Segmental pneumatic appliance for use with pneumatic compressor, full arm Segmental pneumatic appliance, half leg Segmental pneumatic appliance, half leg Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk Segmental gradient pressure pneumatic appliance, full leg Segmental gradient pressure pneumatic appliance, full leg Segmental gradient pressure pneumatic appliance, full arm Segmental gradient pressure pneumatic appliance, full arm Segmental gradient pressure pneumatic appliance, half leg Segmental gradient pressure pneumatic appliance, half leg Pneumatic compression device, high pressure, rapid inflation/deflation cycle Intermittent limb compression device (includes all accessories), not otherwise specified Intermittent limb compression device (includes all accessories), not otherwise specified Transfer device, any type, each Transfer device Passive motion exercise device Continuous passive motion exercise device for use other than knee Commode seat, wheelchair Commode seat, wheelchair Dynamic adjustable elbow extension/flexion device, includes soft interface Static progressive stretch elbow device, extension and or flexion, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable forearm pronation/supination device, includes soft interface Dynamic adjustable wrist extension/flexion device, includes soft interface material Static progressive stretch wrist device, flexion and or extension, with or without range of motion adjustment, includes all components and accessories Dynamic adjustable knee extension/flaxion device, includes soft interface material

17 E1811RR E 1812 RR E1815 RR E1816 RR E1818 RR E 1820 E1821 E1825 RR E1830 RR E1831 RR E1840 RR E1841 RR K0601 K0602 K0603 K0604 K0605 K0607 K0607 RR K0739 K0740 L7360 L7362 DESCRIPTION (Miscellaneous Durabable and Expendable Supplies) Static progressive stretch knee device, etension and or flexion, with or without range of motion ajustment, includes all components and accessories Dynamic knee, extension/flexion device with active resistance control Dynamic adjustable ankle extension/flaxion device, includes soft interface material Static progressive stretch ankle device, flexion and or extension, with or with out range of motion adjustment, includes all components and accessories Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories Replacement soft interface material, dynamic adjustable extension/flexion Replacement soft interface material/cuffs for bi-directional static progressive stretch Dynamic adjustable finger extension/flexion device, includes soft interface material Dynamic adjustable toe extension/flexion device, includes soft interface material Static progressive stretch toe device,, extension and/or flexion, with or without, range of motion adjustment, includes all components and accessories Dynamic shoulder flexion/abduction/rotation device, includes soft interface material Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories DME Not Otherwise Classified Inflatable Bath With Pump Miscellaneous Parts: Repair, Recipient Owned Equipment Pediatric Toilet Training Chair With Hip Strap & Pair of Support Blocks Positioning Device; Any Size; Any Type Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each Replacement battery for external infusion pump owned by patient, lithium 3.6 volt, each Replacement battery for external infusion pump owned by patient, lithium 4.5 volt, each Replacement battery for automated external defibrillator, garment type only, each Replacement battery for automated external defibrillator, garment type only, each Repair or non routine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes Repair or non routine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes Six volt battery, each Battery charger, six volt, each

18 L7364 L7366 L7367 DESCRIPTION (Miscellaneous Durabable and Expendable Supplies) Twelve volt battery, each Battery charger, twelve volt, each Lithium ion, battery replacement